Provider Demographics
NPI:1730494741
Name:O'CONNELL, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:O'CONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-3050
Mailing Address - Fax:
Practice Address - Street 1:1707 W CHARLESTON BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2354
Practice Address - Country:US
Practice Address - Phone:702-671-5150
Practice Address - Fax:702-671-2259
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-02230208600000X
MA268463208600000X
NV204652086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1832ROtherBCBS NC
NC1730494741Medicaid
NC1832ROtherBCBS NC